Alveolar recruitment maneuvers: are your patients missing out?

Awake, spontaneously breathing humans sigh on average 9 to 10 times per hour. The sigh is a normal homeostatic reflex proposed to maintain pulmonary compliance and decrease the formation of atelectasis by recruiting collapsed alveoli. The induction and maintenance of anesthesia with muscle paralysis and a fixed tidal volume abolish the sigh. Without periodic sighs, patients are left susceptible to atelectasis and its negative sequelae. The prevalence of atelectasis has been estimated to be as high as 100% in patients undergoing general anesthesia. A strong correlation between atelectasis and postoperative pulmonary complications has been demonstrated. Postoperative pulmonary complications lengthen hospital stays and increase healthcare costs. Alveolar recruitment maneuvers, which make up one component of open lung ventilation, have been described as vital capacity breaths, double tidal volume breaths, and sigh breaths. These simple maneuvers result in a sustained increase in airway pressure that serves to recruit collapsed alveoli and improve arterial oxygenation. This article examines the literature regarding the application of alveolar recruitment maneuvers in the perioperative setting. The format is a series of clinically oriented questions posed to help the reader translate available evidence into practice.